THE WARREN ALPERT MEDICAL SCHOOL OF BROWN UNIVERSITY GERIATRICS FOR THE Division of Geriatrics PRACTICING PHYSICIAN Quality Partners of RI Department of Medicine EDITED BY ANA C. TUYA, MD House Calls and Home Care Tom J. Wachtel, MD HOUSE CALLS AND DOMICILIARY VISITS The actual visit1 Introduction The history and physical exams in the patient’s home are A growing number of people in the United States are similar to office work. In addition, permission should be re- homebound and need in-home health care services. quested to inspect the living quarters. Is the home clean? Is “House calls” refer to the provision of physician services to there food in the house? Can the patient get around? Is the patients in their homes or apartments, including independent environment safe? Are there loose rugs, nightlights, rails in the living centers. Domiciliary visits refer to physician services pro- bathroom? Medications should be reviewed. vided to patients who reside in assisted living facilities, board- An office visit, no matter how comprehensive, cannot pro- ing houses or group homes. vide a complete understanding of the patient’s daily routine. Home visits may be provided as part of an interdiscipli- In many situations, a family member or other caregiver should nary team or by a solo physician; they may be episodic or exist be present during the visit. When the patient’s condition requires as ongoing care to patients. Furthermore, the diagnostic house substantial nursing care, the visiting nurse should be present dur- call can provide information to the physician about how the ing some visits, enabling the team to discuss the care plan. Observ- patient functions within the home environment. (Table 1). ing the interaction between caregivers and patients is also a valu- able source of information. In the home setting, people may be more likely to display their usual patterns of interaction. In some cases (e.g. abuse or neglect), the physician may need to contact an agency that provides adult protective services. The goals of house calls vary. A “sick” visit may simply address an acute complaint (e.g., respiratory symptoms, a fall). In the case of home-based long term care, the data described in Table 1 should be collected over time or during a comprehensive intake session; included are information on medical problems, physical function (e.g., ADL, IADL) and social and role function, such as visits by friends and relatives; and mental function, affect and advance di- rectives. Unlike the office setting, much of this information can be collected by direct observation during a home visit. Blood and urine tests, electrocardiograms and portable x- rays can be obtained in the home but they must be scheduled in advance and are rarely available on an emergency basis.

Logistics and Time Management The logistics of house calls explain why many physicians, busy with their office and hospital work, find house calls inef- ficient. However, the physician with a substantial caseload of homebound patients can cluster visits geographically. Except for first encounters, multiple house calls can be scheduled per hour when visits are clustered. Routine house calls can replace idle time caused by can- cellations in the office, and improve efficiency. Urgent visits can be made at day’s end. However, it should be made clear to homebound patients that emergencies cannot always be ad- dressed at home, and may require hospital ED.

Payment Codes for House Calls and Domiciliary Visits (effective 1/1/2008) The CPT codes for house calls and domiciliary visits are different. (Table 2) 91 VOLUME 91 NO. 3 MARCH 2008 92 MEDICINE & HEALTH/RHODE ISLAND FORMAL HOME CARE – PHYSICIAN ROLE2 must be provided by a registered nurse or physical, occupa- Introduction tional, or speech therapist. However, just because a service is Formal home care is that care provided to homebound provided by one of these health professionals does not neces- patients by home care agencies. Most agencies are certified as sarily mean it is skilled. A service is skilled because of its com- Medicare providers; a few are not. Some have service con- plexity, its appropriateness for the patient’s condition and be- tracts with health insurers or managed care organizations. They cause it meets accepted standards of medical and nursing prac- typically provide short term, skilled nursing services; rehabili- tice. “Intermittent” means that the skilled services are required tation services including physical, occupational and speech less frequently than 7 days per week, but at least once every 60 therapy; and personal care. Such care must be provided un- days. der physician approval and oversight. Table 4 provides examples of met and unmet eligibility requirements. Documentation should describe the patient’s Regulations condition and the complexity of required services. An assess- When physicians prescribe home care services for Medi- ment of the risk of bad outcomes should the services become care beneficiaries, they must certify that the patient is unavailable is also required. homebound; is in need of intermittent skilled nursing care or physical, speech, or occupational therapy; and under the The Physician as a Gatekeeper physician’s ongoing care. By signing the Medicare authoriza- The eligibility criteria for home care are stringent because tion form, the physician verifies that the patient has met the the intent of the Medicare program is to cover acute care rather three eligibility criteria. The physician must also review the than long-term care. However, the clinical reality is that chronic home care plan periodically, but no less often than every 2 conditions exacerbate and improve over time, causing home months, and re-certify the patient if appropriate. care eligibility to change and complicating the physician’s role in approving services. The (re)certification plan-of-care forms, Homebound Criteria completed by home care agency staff, should document not In order to be eligible for homecare, patients need not be only patients’ current needs for skilled care, but also the rea- bedridden; Medicare considers patients homebound if they sons for their homebound status. Without firsthand knowl- cannot leave their residence independently. Such patients may edge or other reliable information of the patient’s condition, leave their homes with the aid of assistive devices or another the physician should not certify the patient in a perfunctory person, but absences from the home must be relatively short manner by signing a form. and in most instances, be for the purpose of medical treatment. In many cases, there is no doubt that the patient meets the Patients are also considered homebound if leaving the home is Medicare criteria for home confinement. Still, physicians medically contraindicated. should not allow long periods of time to go by without seeing Table 3 lists qualifying clinical situations for Medicare cri- the patient (e.g., 6 months if stable); house calls may be re- teria for home confinement. quired for some patients. Given that an assessment of func- tional status is an integral component of geriatric care, the The Skilled Service Requirement medical record should contain current information about func- A homebound person is not eligible for home care unless tion, in addition to usual medical management issues that will criteria for intermittent skilled care are also met. Skilled care justify patients’ eligibility in case of audit. 93 VOLUME 91 NO. 3 MARCH 2008 The gatekeeping role can be particularly frustrating for ADDITIONAL READINGS patients with chronic conditions, such as congestive heart fail- American Academy of Home Care Physicians: Executive ure (CHF) or emphysema who meet criteria for skilled services Summary, Public Policy Statement, 2005. Edgewood, MD: Ameri- only during episodes of exacerbation. In-home nursing ser- can Academy of Home Care Physicians, 2005. http:// vices for some of those conditions have been shown to reduce wwwaahcp.org/public_policy_2005.pdf exacerbations and hospitalizations, yet regulations impede the Boling P, Abbey L, Keenan J: Home care. In Ham R, provision of evidence-based proven interventions.3 Sloane P, Warshaw G (eds): Primary Care Geriatrics, ed 4. St. Louis, Mosby, 2002: 217-28. Physician payment codes for formal home care oversight Disclosure of Financial Interests Medicare also pays physicians for overseeing the work done Tom Wachtel, MD. Consultant: Proctor & Gamble. by home care agencies. The CPT codes for these services are: Speaker’s Bureau: Proctor & Gamble, Sanofi-Aventis, Pfizer, Boehringer-Ingelheim, Takeda a. G0180 Certification for home care b. G0179 Re-certification for home care 8SOW-RI-GERIATRICS-032008 c. 99374 Care plan oversight for home care: requires at THE ANALYSES UPON WHICH THIS PUBLICATION IS BASED were least 15-29 minutes per month and ability to docu- performed under Contract Number 500-02-RI02, funded by ment the time spent. the Centers for Medicare & Medicaid Services, an agency of 99375 Care plan oversight for home care: 30 min- the U.S. Department of Health and Human Services. The con- utes or more per month tent of this publication does not necessarily reflect the views d. 99377 and 99378 Care plan oversight for hospice or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or (same respective time requirements as for home care). organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and REFERENCES completeness of the ideas presented. 1. Unwin B, Jerant A. The home visit. Am Fam Physician 1999;60:1481-8. 2. Wachtel TJ, Gifford DR. Eligibility for home care certification. J Gen Intern Med 1998;13:705-9. 3. Stewart S, Pearson S, Horowitz JD. Effects of a home-base intervention among patients with CHF discharged from acute hospital care. Arch Intern Med 1998;158:1067-72. 4. Wachtel TJ. Home Care and House Calls. In: Practical Guide to the Care of the Geriatric Patient. Third Edition. Wachtel TJ, Fretwell MD. (eds.) St. Louis, 2007; Mosby: 497-511.

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